A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Maintain IV fluid infusion and assess adequacy of hydration

Provide continuous sedation for pain relief

Insert an indwelling (Foley) catheter and monitor hourly urinary output

Prepare for endotracheal intubation and ventilatory support

Answer and Explanation

The Correct Answer is A

A) Maintain IV fluid infusion and assess adequacy of hydration: This is the best nursing action as adequate hydration is crucial in managing sickle cell crisis. It helps to reduce blood viscosity and prevent further sickling of red blood cells, which is especially important in the context of pneumonia, as dehydration can exacerbate the crisis.

B) Provide continuous sedation for pain relief: While managing pain is essential, continuous sedation is not the most appropriate first step in this situation. Pain management should be addressed, but hydration and treating the underlying causes (like pneumonia) take priority.

C) Insert an indwelling (Foley) catheter and monitor hourly urinary output: While monitoring urinary output can be important, it is not the most immediate action in this case. Focus should be on hydration and addressing the sickle cell crisis rather than on urinary output at this time.

D) Prepare for endotracheal intubation and ventilatory support: Although respiratory distress is a concern with pneumonia, the current pulse oximetry reading of 96% indicates adequate oxygenation at this time. Preparing for intubation should not be the first action unless the patient shows signs of respiratory failure or severe distress.

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Correct Answer is B

Explanation

A. Increase calcium in the diet: While calcium is important, it's not the most critical aspect in managing hypertension compared to weight management.

B. Monitor weight on a weekly basis: Weight management is crucial for clients with hypertension, as fluctuations can indicate changes in fluid retention or overall health. Regular monitoring can help in managing blood pressure.

C. Obtain blood pressure checks twice a year: This is insufficient for monitoring hypertension; more frequent checks are generally recommended.

D. Have yearly eye examinations: While important for overall health, it’s not as directly related to the management of hypertension as monitoring weight.

A. will confirm a diagnosis of G6PD anemia B. is a 24-hour urine specimen collection test! C. involves limiting intake of animal proteins D. entails administration of methylcellulose prior to the test

Correct Answer is B

Explanation

A. "will confirm a diagnosis of G6PD anemia": This statement is incorrect. The Schilling test is specifically used to evaluate vitamin B12 absorption and diagnose conditions like pernicious anemia, not G6PD deficiency.

B. "is a 24-hour urine specimen collection test": This statement is accurate. The Schilling test typically involves collecting a 24-hour urine specimen to measure the amount of radioactively labeled vitamin B12 excreted in the urine, which helps determine if the body is absorbing vitamin B12 properly.

C. "involves limiting intake of animal proteins": This statement is misleading. While dietary restrictions may be necessary for certain tests, the Schilling test primarily focuses on the absorption of vitamin B12 and does not require limiting animal protein intake.

D. "entails administration of methylcellulose prior to the test": This statement is incorrect. Methylcellulose is not involved in the Schilling test. The test typically includes administration of oral vitamin B12 with or without intrinsic factor to evaluate absorption.

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A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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